Some North Carolina dentists hope to create a new kind of mid-level dental worker as a way of expanding care to people in poor and rural areas of the state. But the effort faces a long and arduous road.
Dr. Steven Slott, a Burlington dentist who founded a traveling free clinic, wants the state legislature to study the idea of an entirely new work force of mid-level dental positions. Such an approach has been tried in Alaska and is gaining ground in several other states.
"We have got to get something done in this state," Slott said. "There a huge problem." He noted that four counties have no dentists, six others have severe shortages, and even rich counties struggle to provide care to poor people.
Slott said a mid-level worker could provide simple services more cheaply than regular dentists. Like nurse practitioners or physician assistants, a mid-level dental worker would have extra training and duties.
Notably, the mid-level worker could perform uncomplicated extractions and fillings currently performed only by dentists; hygienists are restricted to such jobs as cleaning teeth.
But the idea is not widely embraced by dentist groups. The American Dental Association has opposed an advanced dental hygienist practitioner model and has fought to limit Alaska's efforts.
The N.C. Dental Society, which in the past has opposed efforts to give hygienists greater autonomy, has not taken a formal position on the growing trend. Dr. Alec Parker, executive director of the state society, said the group is open to considering the prospect of mid-level practitioners.
Is timing right?
But Parker said now is not the best time to press ahead, given the sour economy and plans to expand the dental school at UNC-Chapel Hill and to build a dental school at East Carolina University.
"It just seems to me, and this is my personal opinion, that we would want to see how that goes before we started throwing another unknown into the equation," Parker said, noting that the dental school expansions will result in an additional 68 graduates a year moving into practice. Many of those are likely to be in North Carolina.
Misgivings
A dental society newsletter raised concerns about the idea of mid-level practitioners as momentum across the nation has grown. Aside from Alaska, Minnesota has made the most headway, establishing a new university major for people to learn advanced skills. Connecticut, Maine and Washington are also pressing ahead to establish the new position.
"In other words, they suggest allowing lesser-trained people provide oral health services on the underserved," the N.C. Dental Society newsletter stated.
Slott, the Burlington dentist, said there is no evidence that mid-level practitioners would provide subpar care, and he called for a study group to examine the available research and make a fact-based analysis.
"If we saw a danger, we wouldn't have to proceed," Slott said.
He said his efforts are in the formative stages, as he considers taking his request to legislators or forming a coalition of public health groups to push the idea.
Slott said there is good precedence for overcoming concerns about a mid-level dental technician. In the 1960s, the radical notion of nurse practitioners and physician assistants rankled many doctors. Now, both types of health providers are considered integral.
Dr. Rob Doherty, dental director of Greene County Health Care in Snow Hill, said the time has come for dentistry to expand its profession.
"The only fight is to open our minds and open our hearts a little bit and get that information out there," Doherty said. "I'm not going to put on armor and go slashing through a wall of human flesh here. I just want to get some information."
Serving the poor
Doherty said he doesn't think the new dental school at ECU will solve the state's problem for many people, especially the poor. He said his clinic is overwhelmed with patients, many of whom can't afford the sliding scale fees charged by his not-for-profit practice. Instead, he said, they put off painful tooth conditions until a visiting free clinic comes to town.
"Volunteer service is not a system of health care," Doherty said, referring to the dentists, hygienists and others who donate their time for the free clinics.
Doherty and other proponents said mid-level practitioners could provide care less expensively than dentists. They could charge less for simple procedures, because they would not have the massive student loan bills from dental school, or many of the costs associated with establishing a practice.
Many questions remain, however. Among the thornier issues is how much education the new workers would require and who would license them. Currently in North Carolina, most hygienists graduate with two-year associate degrees from community colleges and are licensed by the state's dental board.
Jonathan Owens, immediate past president of the N.C. Dental Hygiene Association, said the national organization of hygienists prefers a plan to create a master's degree level "superhygienist" who could work independently from a dentist and perform some simple extractions and restorations.
Owens said it's only a matter of time before some form of that job becomes common.
"It's going to happen," Owens said. "It's going to happen in the United States first, and then I think in North Carolina we'll start seeing it."
